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A home health nurse is caring for a child who has Lyme disease.

Which of the following is an appropriate action for the nurse to take?

A.

Ensure the state health department has been notified.

B.

Administer antitoxin

C.

Educate the family to avoid sharing personal belongings.

D.

Assess for skin necrosis

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states.

Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.

Choice B is wrong because antitoxin is not used to treat Lyme disease.

Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.

Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the

bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.

Choice D is wrong because skin necrosis is not a common complication of Lyme disease.

Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.


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Related Questions

Correct Answer is B

Explanation

The correct answer is choice B. How to operate the portable suction machine. The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.

Choice A is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.

Choice C is wrong because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.

Choice D is wrong because the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.

Correct Answer is D

Explanation

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

  • Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg.
  • This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

  • Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided.
  • The weight should be distributed through the hands and wrists,not the armpits.

Choice C rationale:

  • Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

  • Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches.
  • It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

  • Weight is borne on the unaffected leg and the crutches,not the affected leg.
  • The crutches and the unaffected leg move forward together,followed by the affected leg.
  • The client should look ahead,not down at their feet.
  • The client should take small,even steps.
  • The client should rest as needed.

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